| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
3,929 |
3,906 |
$141K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,870 |
1,078 |
$129K |
| D9630 |
|
6,116 |
6,071 |
$98K |
| D1120 |
Prophylaxis - child |
3,186 |
3,170 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
5,301 |
5,277 |
$89K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,815 |
4,796 |
$85K |
| D0274 |
Bitewings - four radiographic images |
2,498 |
2,485 |
$56K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,252 |
2,585 |
$48K |
| D0210 |
Intraoral - complete series of radiographic images |
1,060 |
1,046 |
$48K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
642 |
418 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,656 |
1,639 |
$36K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,089 |
908 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
3,105 |
3,069 |
$29K |
| D2740 |
Crown - porcelain/ceramic |
72 |
51 |
$24K |
| D2950 |
|
143 |
103 |
$16K |
| D0140 |
Limited oral evaluation - problem focused |
344 |
343 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
93 |
$4K |
| D0330 |
Panoramic radiographic image |
39 |
38 |
$2K |
| D1351 |
Sealant - per tooth |
179 |
52 |
$1K |
| D9920 |
|
26 |
26 |
$0.00 |
| D3120 |
|
15 |
12 |
$0.00 |